Basic Information
| Provider Information | |||||||||
| NPI: | 1053514513 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAO | ||||||||
| FirstName: | QINWEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 710 N FAIRBANKS CT STE 2-458 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606113013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129269487 | ||||||||
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| Practice Location | |||||||||
| Address1: | 710 N FAIRBANKS CT STE 2-458 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606113013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2145908058 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2007 | ||||||||
| LastUpdateDate: | 11/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZN0500X | 036125842 | IL | N | Allopathic & Osteopathic Physicians | Pathology | Neuropathology | 207ZP0102X | 036125842 | IL | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | BP1-0022464 | 01 | INSTITUTIONAL PERMIT | OTHER |